Amendment
Bill No. 0881

Amendment No. 179895

CHAMBER ACTION
Senate		House
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1	Representative Sands offered the following:
2
3	Amendment (with title amendments)
4	Between lines 152 and 153 insert:
5	Section 4.  Paragraph (b) of subsection (4) of section
6	409.912, Florida Statutes, is amended to read:
7	409.912  Cost-effective purchasing of health care.--The
8	agency shall purchase goods and services for Medicaid recipients
9	in the most cost-effective manner consistent with the delivery
10	of quality medical care. To ensure that medical services are
11	effectively utilized, the agency may, in any case, require a
12	confirmation or second physician's opinion of the correct
13	diagnosis for purposes of authorizing future services under the
14	Medicaid program. This section does not restrict access to
15	emergency services or poststabilization care services as defined
16	in 42 C.F.R. part 438.114. Such confirmation or second opinion
17	shall be rendered in a manner approved by the agency. The agency
18	shall maximize the use of prepaid per capita and prepaid
19	aggregate fixed-sum basis services when appropriate and other
20	alternative service delivery and reimbursement methodologies,
21	including competitive bidding pursuant to s. 287.057, designed
22	to facilitate the cost-effective purchase of a case-managed
23	continuum of care. The agency shall also require providers to
24	minimize the exposure of recipients to the need for acute
25	inpatient, custodial, and other institutional care and the
26	inappropriate or unnecessary use of high-cost services. The
27	agency may mandate prior authorization, drug therapy management,
28	or disease management participation for certain populations of
29	Medicaid beneficiaries, certain drug classes, or particular
30	drugs to prevent fraud, abuse, overuse, and possible dangerous
31	drug interactions. The Pharmaceutical and Therapeutics Committee
32	shall make recommendations to the agency on drugs for which
33	prior authorization is required. The agency shall inform the
34	Pharmaceutical and Therapeutics Committee of its decisions
35	regarding drugs subject to prior authorization. The agency is
36	authorized to limit the entities it contracts with or enrolls as
37	Medicaid providers by developing a provider network through
38	provider credentialing. The agency may limit its network based
39	on the assessment of beneficiary access to care, provider
40	availability, provider quality standards, time and distance
41	standards for access to care, the cultural competence of the
42	provider network, demographic characteristics of Medicaid
43	beneficiaries, practice and provider-to-beneficiary standards,
44	appointment wait times, beneficiary use of services, provider
45	turnover, provider profiling, provider licensure history,
46	previous program integrity investigations and findings, peer
47	review, provider Medicaid policy and billing compliance records,
48	clinical and medical record audits, and other factors. Providers
49	shall not be entitled to enrollment in the Medicaid provider
50	network. The agency is authorized to seek federal waivers
51	necessary to implement this policy.
52	(4)  The agency may contract with:
53	(b)  An entity that is providing comprehensive behavioral
54	health care services to certain Medicaid recipients through a
55	capitated, prepaid arrangement pursuant to the federal waiver
56	provided for by s. 409.905(5). Such an entity must be licensed
57	under chapter 624, chapter 636, or chapter 641 and must possess
58	the clinical systems and operational competence to manage risk
59	and provide comprehensive behavioral health care to Medicaid
60	recipients. As used in this paragraph, the term "comprehensive
61	behavioral health care services" means covered mental health and
62	substance abuse treatment services that are available to
63	Medicaid recipients. The secretary of the Department of Children
64	and Family Services shall approve provisions of procurements
65	related to children in the department's care or custody prior to
66	enrolling such children in a prepaid behavioral health plan. Any
67	contract awarded under this paragraph must be competitively
68	procured. In developing the behavioral health care prepaid plan
69	procurement document, the agency shall ensure that the
70	procurement document requires the contractor to develop and
71	implement a plan to ensure compliance with s. 394.4574 related
72	to services provided to residents of licensed assisted living
73	facilities that hold a limited mental health license. Except as
74	provided in subparagraph 8., the agency shall seek federal
75	approval to contract with a single entity meeting these
76	requirements to provide comprehensive behavioral health care
77	services to all Medicaid recipients not enrolled in a managed
78	care plan in an AHCA area. Each entity must offer sufficient
79	choice of providers in its network to ensure recipient access to
80	care and the opportunity to select a provider with whom they are
81	satisfied. The network shall include all public mental health
82	hospitals. To ensure unimpaired access to behavioral health care
83	services by Medicaid recipients, all contracts issued pursuant
84	to this paragraph shall require 80 percent of the capitation
85	paid to the managed care plan, including health maintenance
86	organizations, to be expended for the provision of behavioral
87	health care services. In the event the managed care plan expends
88	less than 80 percent of the capitation paid pursuant to this
89	paragraph for the provision of behavioral health care services,
90	the difference shall be returned to the agency. The agency shall
91	provide the managed care plan with a certification letter
92	indicating the amount of capitation paid during each calendar
93	year for the provision of behavioral health care services
94	pursuant to this section. The agency may reimburse for substance
95	abuse treatment services on a fee-for-service basis until the
96	agency finds that adequate funds are available for capitated,
97	prepaid arrangements.
98	1.  By January 1, 2001, the agency shall modify the
99	contracts with the entities providing comprehensive inpatient
100	and outpatient mental health care services to Medicaid
101	recipients in Hillsborough, Highlands, Hardee, Manatee, and Polk
102	Counties, to include substance abuse treatment services.
103	2.  By July 1, 2003, the agency and the Department of
104	Children and Family Services shall execute a written agreement
105	that requires collaboration and joint development of all policy,
106	budgets, procurement documents, contracts, and monitoring plans
107	that have an impact on the state and Medicaid community mental
108	health and targeted case management programs.
109	3.  Except as provided in subparagraph 8., by July 1, 2006,
110	the agency and the Department of Children and Family Services
111	shall contract with managed care entities in each AHCA area
112	except area 6 or arrange to provide comprehensive inpatient and
113	outpatient mental health and substance abuse services through
114	capitated prepaid arrangements to all Medicaid recipients who
115	are eligible to participate in such plans under federal law and
116	regulation. In AHCA areas where eligible individuals number less
117	than 150,000, the agency shall contract with a single managed
118	care plan to provide comprehensive behavioral health services to
119	all recipients who are not enrolled in a Medicaid health
120	maintenance organization. The agency may contract with more than
121	one comprehensive behavioral health provider to provide care to
122	recipients who are not enrolled in a Medicaid health maintenance
123	organization in AHCA areas where the eligible population exceeds
124	150,000. Contracts for comprehensive behavioral health providers
125	awarded pursuant to this section shall be competitively
126	procured. Both for-profit and not-for-profit corporations shall
127	be eligible to compete. Managed care plans contracting with the
128	agency under subsection (3) shall provide and receive payment
129	for the same comprehensive behavioral health benefits as
130	provided in AHCA rules, including handbooks incorporated by
131	reference. Notwithstanding the provisions of this section,
132	Medicaid-eligible individuals within District 10 who receive
133	comprehensive inpatient and outpatient mental health and
134	substance abuse services under the MediPass program may choose
135	to continue to receive services under this program.
136	4.  By October 1, 2003, the agency and the department shall
137	submit a plan to the Governor, the President of the Senate, and
138	the Speaker of the House of Representatives which provides for
139	the full implementation of capitated prepaid behavioral health
140	care in all areas of the state.
141	a.  Implementation shall begin in 2003 in those AHCA areas
142	of the state where the agency is able to establish sufficient
143	capitation rates.
144	b.  If the agency determines that the proposed capitation
145	rate in any area is insufficient to provide appropriate
146	services, the agency may adjust the capitation rate to ensure
147	that care will be available. The agency and the department may
148	use existing general revenue to address any additional required
149	match but may not over-obligate existing funds on an annualized
150	basis.
151	c.  Subject to any limitations provided for in the General
152	Appropriations Act, the agency, in compliance with appropriate
153	federal authorization, shall develop policies and procedures
154	that allow for certification of local and state funds.
155	5.  Children residing in a statewide inpatient psychiatric
156	program, or in a Department of Juvenile Justice or a Department
157	of Children and Family Services residential program approved as
158	a Medicaid behavioral health overlay services provider shall not
159	be included in a behavioral health care prepaid health plan or
160	any other Medicaid managed care plan pursuant to this paragraph.
161	6.  In converting to a prepaid system of delivery, the
162	agency shall in its procurement document require an entity
163	providing only comprehensive behavioral health care services to
164	prevent the displacement of indigent care patients by enrollees
165	in the Medicaid prepaid health plan providing behavioral health
166	care services from facilities receiving state funding to provide
167	indigent behavioral health care, to facilities licensed under
168	chapter 395 which do not receive state funding for indigent
169	behavioral health care, or reimburse the unsubsidized facility
170	for the cost of behavioral health care provided to the displaced
171	indigent care patient.
172	7.  Traditional community mental health providers under
173	contract with the Department of Children and Family Services
174	pursuant to part IV of chapter 394, child welfare providers
175	under contract with the Department of Children and Family
176	Services in areas 1 and 6, and inpatient mental health providers
177	licensed pursuant to chapter 395 must be offered an opportunity
178	to accept or decline a contract to participate in any provider
179	network for prepaid behavioral health services.
180	8.  For fiscal year 2004-2005, all Medicaid eligible
181	children, except children in areas 1 and 6, whose cases are open
182	for child welfare services in the HomeSafeNet system, shall be
183	enrolled in MediPass or in Medicaid fee-for-service and all
184	their behavioral health care services including inpatient,
185	outpatient psychiatric, community mental health, and case
186	management shall be reimbursed on a fee-for-service basis.
187	Beginning July 1, 2005, such children, who are open for child
188	welfare services in the HomeSafeNet system, shall receive their
189	behavioral health care services through a specialty prepaid plan
190	operated by community-based lead agencies either through a
191	single agency or formal agreements among several agencies. The
192	specialty prepaid plan must result in savings to the state
193	comparable to savings achieved in other Medicaid managed care
194	and prepaid programs. Such plan must provide mechanisms to
195	maximize state and local revenues. The specialty prepaid plan
196	shall be developed by the agency and the Department of Children
197	and Family Services. The agency is authorized to seek any
198	federal waivers to implement this initiative.
199
200	================ T I T L E  A M E N D M E N T =============
201	Remove line 28 and insert:
202	amending s. 409.912, F.S.; providing for certain Medicaid-
203	eligible individuals to continue receiving comprehensive
204	inpatient and outpatient mental health services; providing an
205	effective date.

CODING: Words stricken are deletions; words underlined are additions.